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Journal of the Chinese Medical Association xx (2017) 1e4
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Original Article

A new facilitating technique for postpartum hysterectomy at full dilatation:

Cervical clamp
Ozan Dogan a,*, Cigdem Pulatoglu b, Murat Yassa c
a
Department of Obstetrics and Gynecology, Ataturk Duzce State Hospital, Duzce, Turkey
b
Department of Obstetrics and Gynecology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
c
Department of Obstetrics and Gynecology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
Received January 9, 2017; accepted May 15, 2017

Abstract

Background: Postpartum hysterectomy is a life saving emergency procedure in the management of uncontrollable severe maternal hemorrhage
that every obstetrician should be closely acquainted with despite developments in medical and non-surgical interventions for obstetric hem-
orrhage. It can be difficult to detect the real boundaries of the cervix at full effacement and dilatation in patients who undergo emergency
hysterectomy after vaginal delivery.
Methods: Hereby we propose a simple and effective method to ease the operation by placing two atraumatic ring forceps to the anterior and
posterior sides of the cervix during the preoperative vaginal examination and leave the two ring forceps while taking the patient into surgery. The
boundary of the vagina and cervix will be determined with the help of the ring forceps intraoperatively, which are already placed before the
operation.
Results: Cervical clamp technique was successfully performed in four cases underwent to emergency postpartum hysterectomy due to un-
controllable postpartum atony. There were no postoperative complication and re-exploration for the persistent hemorrhage. Postoperative FSFI
scores of the cases were 26.7, 27.4, 30.3 and 30.7.
Conclusion: Taking extra vaginal tissue from the lower level of the cervix may be avoided and the last stage of the total hysterectomy may be
facilitated by this simple technique with ensuring of bleeding management.
Copyright © 2017, the Chinese Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Cervical clamp; Postpartum hemorrhage; Postpartum hysterectomy

1. Introduction conservative practices. Other risk factors for PPH include

The most common preventable causes of maternal mortality
leading to postpartum hemorrhage (PPH) deaths involve inad-
equate surgical hemostasis.1 The vast majority of the hyster-
ectomy indications after vaginal birth is uterine atony with
uncontrollable hemorrhage that do not respond to the
Conflicts of interest: The authors declare that they have no conflicts of interest
related to the subject matter or materials discussed in this article.
* Corresponding author. Dr. Ozan Dogan, Department of Obstetrics and
Gynecology, Ataturk Duzce State Hospital, Sahin sokak, Sahin apt. 6 Merkez,
Duzce, Turkey.
E-mail address: ozandogan02@hotmail.com (O. Dogan).
abnormal placentation, coagulopathies, retained placenta,
precipitated or prolonged labor, fetal macrosomia or multi-
parity, maternal obesity and previous primary PPH.2 Incidence
of emergency postpartum hysterectomy (EPH) varies from 0.1
to 0.3 per 1000 vaginal deliveries with a declining ratio due to
the developments in standard obstetric care.3,4 Although the
incidence is low, it represents a major operation in modern
obstetric practice as it is directly related with maternal
morbidity and mortality.5 Despite the obstetric hysterectomy
technique shows similarity with the abdominal hysterectomy in
gynecologic cases, it holds specific surgical difficulties because
of physiological and anatomical changes that occur during

http://dx.doi.org/10.1016/j.jcma.2017.05.010
1726-4901/Copyright © 2017, the Chinese Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Dogan O, et al., A new facilitating technique for postpartum hysterectomy at full dilatation: Cervical clamp, Journal of the
Chinese Medical Association (2017), http://dx.doi.org/10.1016/j.jcma.2017.05.010
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2 O. Dogan et al. / Journal of the Chinese Medical Association xx (2017) 1e4
pregnancy. Subtotal hysterectomy is technically simpler, safer
in terms of urinary tract injury and needs less skill when
compared to total hysterectomy. However, bleeding from the
lower segment and insufficient hemorrhage control may
conduce to total hysterectomy. Difficulties in identifying the
borders of the effaced cervix in women who have labored at
full dilatation conclude with operative problems in total hys-
terectomy.6,7 It can lead to incomplete removal, excessive loss
of vaginal tissue and increased risk of urethral injury when
doing total hysterectomy due to the loss of cervico-vaginal
junction and the limited exposure caused by heavy bleeding.
2. Methods
2.1. Technique: cervical clamp
Determining the borders of the cervix surgically in emer-
gency hysterectomies after vaginal delivery can be a chal-
lenging issue. It could be easy to detect the boundaries of the
cervix with full effacement and dilatation with our technique.
The clamps (ring forceps), which does not harm the tissue, are
placed to the cervix with full effacement and full dilatation by
the 6th and 12th o'clock positions during the vaginal exami-
nation in lithotomy position while evaluating the postpartum
hemorrhage (Fig. 1).
If the decision inevitably turns to hysterectomy despite all
the efforts and alternative methods routine hysterectomy pro-
cedures are swiftly followed. Bilateral round ligament, ovarian
ligament and uterine arteries are clamped, cut and ligated with
the use of Haney clamps. The bladder and rectum are dissected
off the lower end of the uterus and subsequently priorly placed
clamps are reached. After determining the boundaries of the
cervix and vagina with the help of the ring forceps, cardinal
ligaments clamped, cut and ligated. An incision made right
above the anterior and posteriorly palpated clamps, clamps are
removed transvaginally and the uterus is extracted totally after
anterior and posterior incisions are closed.
3. Results
Retrospective clinical data of four cases underwent to
emergency postpartum hysterectomy due to postpartum atony
Fig. 1. Placing cervical clamps preoperatively at full dilatation.
Please cite this article in press as: Dogan O, et al., A new facilitating technique for postpartum hysterectomy at full dilatation: Cervical clamp, Journal of the
Chinese Medical Association (2017), http://dx.doi.org/10.1016/j.jcma.2017.05.010
and massive maternal hemorrhage after vaginal delivery were
given below to support the concept of using cervical clamp.
Two cases were presented with postpartum atony subse-
quent to partus precipitatus. First of those two was 24 years
old, primigravida nulliparous woman. Cervical clamps were
placed during the transvaginal examination and left in place to
assist the laparotomy or hysterectomy if needed by deter-
mining the borders of the cervix. Emergency laparotomy was
performed due to the abundant hemorrhage resistant to med-
ical interventions. Total hysterectomy decision was taken after
rapid decrease in hemoglobin levels from 15, 1 mg/dl to
4,95 mg/dl and the failure of ligamentum ovarii proprium and
uterine artery ligation. 5 units of whole blood, 16 units of
erythrocyte suspension, 16 units of fresh frozen plasma and 6
units of thrombocyte suspension were required to obtain he-
modynamic stability.
The second case with partus precipitatus was 41 years old,
gravid 8 and para 6. Total hysterectomy decision was taken
after rapid decrease in hemoglobin levels from 10, 2 mg/dl to
4, 35 mg/dl and the failure of ligamentum ovarii proprium,
uterine artery and hypogastric artery ligation. 6 units of
erythrocyte suspension and 6 units of fresh frozen plasma were
required.
Third case was 34 years old, gravid 3 para 2 and presented
with fetal macrosomia. Total hysterectomy decision was taken
after rapid decrease in hemoglobin levels from 11, 7 mg/dl to
5, 5 mg/dl and the failure of ligamentum ovarii proprium,
uterine artery, hypogastric artery ligation and B-Lynch suture.
3 units of whole blood, 6 units of erythrocyte suspension and 6
units of fresh frozen plasma were required.
Fourth case was 36 years old gravid 5 para 3 and presented
with prolonged second stage of labor. Total hysterectomy
decision was taken after rapid decrease in hemoglobin levels
from 12, 4 mg/dl to 3, 5 mg/dl and the failure of ligamentum
ovarii proprium, uterine artery, hypogastric artery ligation and
B-Lynch suture. 3 units of whole blood, 8 units of erythrocyte
suspension, 8 units of fresh frozen plasma and 6 units of
thrombocyte suspension were required to obtain hemodynamic
stability.
All four cases were required postoperative care in intensive
care unit for 5, 3, 3 and 5 days, respectively. Newborn of the
first case required 13 days of NICU. There were no post-
operative complication and re-exploration for the persistent
hemorrhage. All cases were discharged uneventfully. The FSFI
scores were obtained at 6th month in the first and second cases
(12 months did not lapsed yet) and at 12th month in the third
and fourth cases. FSFI scores of the cases were 26.7, 27.4,
30.3 and 30.7, respectively.
4. Discussion
We propose a simple and effective method to ease deter-
mining the borders of the cervix in the emergency postpartum
hysterectomy by placing two atraumatic ring forceps to the
anterior and posterior sides of cervix during the preoperative
vaginal examination and leave during the surgery. The pro-
posed cervical clamp technique successfully eased the
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O. Dogan et al. / Journal of the Chinese Medical Association xx (2017) 1e4
emergency postpartum total hysterectomy without any
complication and also with reassuring postoperative sexual
function. Despite it was shared a very limited postpartum
hysterectomy cases with using preoperative cervical clamp
technique, we still believe that these were clinically relevant
since emergency maternal postpartum hemorrhage resistant
to medical treatment and conservative methods is not
common.
The leading indication of the postpartum hysterectomy is
changing from uterine atony to placental abnormalities.8
Nowadays more women apply to trial of labor after previous
cesarean section. In a recent study, EPH required in 0.99% of
the patients during the trial of labor.9 While the changes in
trends of delivery choice make the importance of EPH more
apparent, type of hysterectomy is a matter of debate. EPH has
still high priority in the management of obstetrical hemorrhage
although it is rare and chosen as a last option. EPH can be
needed to be performed despite advancements in conservative
methods in modern obstetrics such as angiographic selective
embolization and intrauterine balloon tamponing.10e13
Currently the proportion of subtotal hysterectomy per-
formed for EPH ranges from 20% to 81%.14,15 Thakar and his
friends mentioned that injury to the nerve bundle passing from
the upper vagina inhibits lubrication and orgasm during sexual
intercourse.16 Jewet and his friends reported that shortening of
the vagina may cause dyspareunia after total hysterectomy.17
Both total and subtotal hysterectomy are associated with
high and similar maternal mortality.4,18,19 In cases of uterine
atony, subtotal hysterectomy is often related with shorter
operation times, shorter hospital stay and also associated with
a smaller risk of visceral injuries, particularly urinary tract
injuries.4,19,20 However, subtotal hysterectomy may not
appropriate in cases of bleeding from the lower uterine
segment associated with placenta accreta or previa.4,5,20 Total
hysterectomy may be considered the choice of the conclusive
operation type when active bleeding occurs from lower uterine
segment as the intact cervical branch of uterine artery or
placental abnormalities may cause persistent bleeding.2,4,7,18
Ureter progress from cervix and upper vaginal area, con-
tinues in an 1, 5e2 cm intramural tunnel at the base of the
bladder and opens to the bladder to form trigon. Cervical
effacement and dilatation during vaginal delivery changes the
anatomical progress of the ureter. If the boundaries of the
cervix can not be clearly identified, EPH performed at the
lower level including the upper area of the vagina may cause
ureter injury.21,22 It is recommended that the choice of subtotal
versus total hysterectomy be individualized considering the
patient's condition.2,4
However, determining the portio vaginalis is mostly diffi-
cult during the surgery and one of the reason is the full cer-
vical dilatation and effacement after a vaginal delivery.23 We
realized that there is no major contribution or suggestion to
overcome this issue in the literature except palpation. The only
but unreliable method was proposed by Eltabbakh and Watson
in 1995 is to use the thumb and forefinger to feel the lower
Please cite this article in press as: Dogan O, et al., A new facilitating technique for postpartum hysterectomy at full dilatation: Cervical clamp, Journal of the
Chinese Medical Association (2017), http://dx.doi.org/10.1016/j.jcma.2017.05.010
3
extent of the cervix and eventually the external os by
following the lower uterine segment and to explore the
endocervical canal after incising the lower uterine segment.7
Our method is simple and can be performed by every
obstetrician in clinical practice. Further researches should aim
to compare total versus subtotal hysterectomy with using this
technique that we also expect to form a clinical trial soon.
Using this method may eliminate the potential disadvantages
of total hysterectomy after vaginal delivery by facilitating to
determine the borders of the cervix. Thus, taking extra vaginal
tissue from the lower level of the cervix may be avoided.
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Please cite this article in press as: Dogan O, et al., A new facilitating technique for postpartum hysterectomy at full dilatation: Cervical clamp, Journal of the
Chinese Medical Association (2017), http://dx.doi.org/10.1016/j.jcma.2017.05.010